Provider Demographics
NPI:1356323919
Name:MCEOWEN, EDWIN L (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:L
Last Name:MCEOWEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3640 NEW VISION DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1717
Mailing Address - Country:US
Mailing Address - Phone:260-482-4440
Mailing Address - Fax:260-482-4442
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-373-4000
Practice Address - Fax:260-482-4442
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01028980207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200033240Medicaid
MI104874507Medicaid
00000003659OtherMPLAN
OH2517191Medicaid
IN000000082542OtherANTHEM
OH2517191Medicaid
MI104874507Medicaid
IN000000082542OtherANTHEM